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INVENTORY RECONCILIATION <br /> QUARTERLY SUMMARY <br /> REPORT FORM <br /> Facility Name: �/�/ , �/ a�sbdi� 1 n c . Tank t Size Product <br /> �J / / C' c <br /> Facility Address: �� 'J- Q2 g [1 1 ll c�' > > - <br /> e C. C' <br /> Telephone : S- v% <br /> Person Fil' 8 _ <br /> Report <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (Ho in Column 13of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) release. (Yes in Coles 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank 1, and amount for all variations that exceeded the <br /> allowable limits. pp <br /> Date Tank Amount v l <br /> . 4 , <br /> 2• ©r <br /> 3. 7 <br /> 4. <br /> 5 <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. .. <br /> IE the source of the variation which exceeded allowable limits was due to <br /> a leak the incident shall be reported to S .J .L.H . D. Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> Quarter I - January March <br /> Quarter 2 - April --> June <br /> Quarter 3 - July = --) September <br /> Quarter 4 - October December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . Hazelton , P .O . Box 2009 <br /> Stockton , CA 95201 466-6781 <br /> UGT 40 10/86 <br />